Customer InformationCompany NameDepartmentAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Contact Name First Last Contact PhoneContact Email Radio Unit InformationFor additional units please scroll to the bottom of this form. Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Do you need an estimate before a repair is made? (If NO, repairs will be made without prior authorization and you will be invoiced.)YesNoBilling InformationBilling Options Current HWS customer with established payment terms Not a current HWS customer, will pay by credit card *Authorization form required* HWS Maintenance Contract Customer HWS Rental Plan PO Required Return Method UPS Ground Customer Pick Up HWS Delivery Labor fee is $90 / hour per unit. Manufacture may refuse warranty service on abused equipment (i.e. water damage, misuse, physical damage), and that you may be invoiced for the value of the Replacement and/or service fees. If the unit is returned from the manufacture with no defect found, I understand I will be invoiced for service processing fee of $35.00. All batteries will be inspected and tested, if they fail to meet the manufacture’s specifications, they will be replaced, and you will be invoiced for replacements.Authorizing Signature (Please Type Name)Additional RadiosSerial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket Serial #Model #Type Mobile Portable ProblemAccessories Included Battery Antennae Clip Dust Cover Charger Power Supply Remote Mic Headset Bracket
